The Pharmacy Chick

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Prudent prescribing or overdone? Should ALL discomfort be treated like this?

Filed under: Uncategorized — pharmacychick at 5:50 pm on Monday, September 10, 2012

She came in smartly dressed, probably in her late 20′s or early 30′s. She had a prescription for an antibiotic and 30 Percocet.  After I collected all the appropriate information, her cell phone rang and it was her mother…( since she referred to her as “mom” I assume I have the correct person).

Her call went as follows:  ” hey mom, whats up?…..no, I’m not at work I am at the pharmacy, I had a sore throat so I went to the doctor and he gave me some antibiotics and something for my throat…..nah, its not big deal, I’ll still be there tonight..what does it start??  Sure, I’ll pick you up at 6 ok?”  click.

I looked at her profile, and not much stood out.  Birth control, some allergy meds that dated back awhile, and a cough syrup last November.  Nothing to speak of.

I looked down at my rx…Percocet 5/325 #30. Has it come to be so commonplace to us that we prescribe powerful pain medications for sore throats?  That will probably be gone in 24 hours once the antibiotics kick in?? It didn’t seem all that long ago that childbirth may have gotten you some Tylenol 3.  All your wisdom teeth extracted may have gotten you a dozen Percocet.

My narc cabinet is full of stuff…way more stuff than I used to need.  I sent 2-3  222 blanks full of orders each week, whereas I used to order a couple of times per month.   What is the rationale? Is it justified? Is it overkill?

And please, no comments from chronic pain patients crawling on their soap box trashing me and my profession.  This isn’t about you.

I am quite used to this urgent care clinic’s prescribing practices.  They have two docs: one that happily hands out percocet for everything and one that writes magic mouthwash instead.

Personally, I think its a bit much. I could think of some appropriate alternatives.

Just a monday observation…back to the grindstone tomorrow!

24 Comments »

Comment by C

September 11, 2012 @ 2:47 am

Overdone.

Magic Mouthwash is the bomb. Sore throats, after tooth extractions, etc.

Percocet is great for post surgical pain but a sore throat? Wow.

And no, this is NOT about chronic pain.

Comment by Mal

September 11, 2012 @ 4:08 am

I don’t know, I’ve had a strep throat that I would happily have taken percocet for, had it been offered. Though of course, I couldn’t eat, could hardly speak, and it was agony to swallow.

I just got antibiotics and lozenges.

Comment by JS

September 11, 2012 @ 6:59 am

If the sore throat was that bad that she needed Percocet I have to wonder how will she swollow those (or the antibiotic) and be able to pick her Mom up @ 6:00? B/f my feeding tube when I had strep throat I would ask for a liquid antibiotic (I didn’t get pain meds nor would I think to ask) and Hycodan if needed (if Tessalon came liquid that would be perfect; better even). When my throat hurts that bad, I can’t swallow my own saliva let alone pills?

How are you feeling, by the way? What a bunch of scary weeks that had to have been fir you? So glad your doing okay?

Comment by Loren Pechtel

September 11, 2012 @ 8:14 am

This makes no sense. I’ve had pain stuff for a sore throat once in my life–tylenol #3. It was quite adequate–and it was liquid because trying to swallow a tablet would have been difficult.

You need something much heavier than that and plan to swallow a tablet of it????

Comment by Jade

September 11, 2012 @ 2:57 pm

I wasn’t able to say much, let alone try to make myself heard on a telephone when I had very sore mess of a viral upper respiratory infection.

Comment by PharmD Blogger

September 11, 2012 @ 5:00 pm

I used to only do a couple of 222 forms a month back in the day. Now I do at least one full DEA 222 form a week. There are way more C2s now than there ever was. I haven’t received a prescription for Percocet for a cough before, but I do know what you mean with the magic mouthwash. I think it is getting a little out of hand, also.

Comment by Mickey

September 11, 2012 @ 8:18 pm

you’re not crazy … yes, it’s over the top. Personally I thank god for CSOS! I cannot stand 222′s. I’ll never forget my “girl friday” who on filled out a 222, and left for vacation on her birthday… she dated the 222 8/12/1968 … needless to say, we never got the narcotics :)

Comment by Pharmacy Jim

September 11, 2012 @ 9:51 pm

Yes, it is out of hand. As stated previously, CSOS certainly helps. Sigh, I spend WAY too much time tracking doctor/pharmacy shoppers on PMP.

Comment by JJ

September 12, 2012 @ 10:21 am

Not only do I think we are overdoing it with the pain meds for the simple things, I wonder to what level this will escalate?

What info are the prescribers receiving that causes them to prescribe the heavy hitters? Are med schools ramping up their teaching of using more powerful narcs?

Some pain in life in inevitble. It is good to learn to deal with some minor discomfort. Let’s try some plain tylenol next time!

Comment by bcmigal

September 12, 2012 @ 10:50 am

Surely you jest! When I got my wisdom teeth yanked I got 12 Percocet! Had strep as an adult and got nothing but pen vk and a note to take ibuprofen. That MD is an addict’s dream doc.

Comment by Frantic Pharmacist

September 12, 2012 @ 1:25 pm

Totally agree. And even if it was a HORRIBLY painful strep throat, how about 10 Percocet instead of 30 ??
I think all community pharmacists agree this has gotten totally out of hand. Yeah, and what IS IT with this magic mouthwash nonsense?? I thought I was the only one…..

Comment by MAP

September 13, 2012 @ 7:42 am

30 percocet for a sore throat?!@# Very over the top. Seeing it more and more — powerful pain meds and large quantities of these pain meds for less than severe pain. A lidocaine vicious rinse in my opinion is still too much. It seems that people are so intolerant of pain these days that they don’t want ANY pain. Pain can be a helpful thing and let’s you know you’re alive.

Of course, it’s interesting how quick the prescribers are to prescribe. I went in for a knee injury — was able to work, still ride my bicycle, walk for short distances, just couldn’t stand for 14-hour shifts — needed to alternate between standing and sitting. Anyway, the first thing the prescriber wanted to do was write me a script for pain medication. I refused and suggested pain meds would not be beneficial in decreasing inflammation. I suggested to the prescriber that OTC ibuprofen, ice, compression, elevation, rest, and limiting the amount of standing would be more beneficial. He looked really surprised at my suggestions, but quickly agreed. I then also suggested that Voltaren gel would be a good product to try. He seemed overjoyed with the suggestion. The knee is coming along nicely especially after a steroid injection about 2 months later when the inflammation was still hanging around.

I also see prescribers writing a lot of pain meds for children these days that seems really excessive. I have a good talk with parents about these meds and recommend they don’t tell the children what the medication is and to give half the prescribed dose for the shortest number of days. I let them know their children will have lots of new friends wanting to come over if word gets out they are on pain meds and that their house would become a target for break-ins, etc. I also suggest they put the meds in a safe place — even in a safe or lock box to prevent children/teens from getting to them.

MAP

Comment by MAP

September 13, 2012 @ 7:46 am

One other note — Tylenol/APAP is ineffective when used for pain that is caused by inflammation — such as strep throat pain. Ibuprofen, Aleve, and even ASA are more beneficial since they are NSAIDS — of course, all taken with food.

MAP

Comment by Dr. Apothecary

September 13, 2012 @ 6:44 pm

MAP, Tylenol/APAP is perfectly fine to use for a sore throat. They’re anti-pain medications. That’s what they’re there for.

Sore throats are not really the inflammation that NSAIDs are better for. Back pain or knee pain due to inflamed muscle would be treated better with NSAIDs (as long as they’re at higher prescription doses, as the lower OTC doses are really just for pain relief). Rx doses of NSAIDs would help reduce the inflammation and help with healing. But Tylenol would still help reduce pain and for someone with a history of ulcers/GI bleeds, would be the better/only choice.

And, by the way, aspirin is not really an NSAID. It’s similar, but it’s never used for inflammation (my guess is because it’d be too toxic on the stomach at the required doses, but that’s just a guess). At pain-relief doses, though, it’s apparently great for a headache.

Comment by Dr. Apothecary

September 13, 2012 @ 6:58 pm

Oh, and I just read your first post more closely, MAP. You seriously are recommending for parents to give their child half the recommended dose of pain medications that has been prescribed by their doctor???? I seriously hope that you at least make sure what you’re recommending is still in the effective range of doses. Not that I agree with this practice. You don’t know the whole clinical situation of the kids. Would you also tell the parents to give half the antibiotic if you disagreed with the dose? If you disagree with the dose, you call the doctor. You don’t tell the parents to do something different than what’s prescribed.

And with parents not telling the kids that they’re giving them pain medication would mean that the parents wouldn’t be responding to the kids’ pain levels when they give the kids medication. Children have overdosed on pain medication, specifically liquid oxycodone, when parents have given it around the clock and not understood that it was as needed. Maybe you should instead tell the parents to tell their kids that their Rx is a powerful pain medication that can be very dangerous if mis-used. Parents can also explain to kids that people mis-use the med and not to widely share that they are taking it. Lastly, we should be recommending that the parents dispose of any med left over to help keep narcotics away from house guests and kids. That’s even better than keeping it locked up.

Comment by old fashioned doc

September 14, 2012 @ 8:00 am

“What info are the prescribers receiving that causes them to prescribe the heavy hitters?”

Patient satisfaction scores.

Comment by Crazy RxMan

September 15, 2012 @ 11:09 am

My pharmacy has more narcs than anyone within 20 miles. And that’s a problem because the word is out and people come for miles… first because we have them in stock, and second, my pharmacy manager says he’s not a “Policeman Paul” and doesn’t care if they’ve had it last week, yesterday, or three hours ago. So I have to be the bad guy and tell people no on my shift. So if you have a prescriber handing out juicy-juice and my pharmacy manager is there, it’s candy day at the pharmacy.

Arrrrgggghhhhh!

Comment by Wrong Aid

September 15, 2012 @ 7:11 pm

Where do you think “chronic pain” patients come from. A few Percocet here, a few Lortab there. No better patient than an addicted one.

The stuff should be banned. Absolutely no need for any of this stuff outside of open wounds and broken bones. All day long I’m filling antibiotics and pain pills. Sinus and bladder infections. You all know why it happens. Are you afraid to put it in print? If those docs didn’t prescribe the hard stuff 50% or more of those patients wouldn’t bother to even come to the ER or the clinic. It’s better business.

Comment by amy

September 17, 2012 @ 5:06 pm

Hmmmm, anyone consider that maybe she was lying to her mom about the actual issue. I am currently in the hospital recovering from sepsis. My mom thinks I just have a kidney infection (which technically I did have, before I went septic). I am almost 42 years old, if she knew I had sepsis, she would be out of her mind crazy with worry and thus driving me crazy……yeah not all phone calls with “mom” can be taken at face valuenah, I thought about that also, but she didn’t look to me like she was covering up any suffering. had she been absolutely miserable, I think it would have been evident at the pharmacy counter, where she had nothing to shield us from. And, since she was going to some event/concert/dinner in about an hour, “mom” would surely figure it out. But I appreciate your assessment.

Comment by Pharmacist Gal

September 20, 2012 @ 8:36 am

I saw a news story on T.V. the other night, about a study which showed that military doctors were prescribing excessive amounts of narcotic pain meds to wounded soldiers, and creative addicts as a result. Duh, I have had patients with TriCare prime (active duty for those not familiar) who present with prescriptions for 180 tablets of Oxycodone 30 mg. I know they may be on medical leave and not discharged yet, but what is the future for this soldier? Luckily, the doctors in my area haven’t started using Percocets for sore throats. Also most of the ER docs around here limit pain meds to 10, or 12 tablets.

Comment by Ranger112

September 24, 2012 @ 11:12 pm

Pharmacist telling Parents to give children a different dose then prescribed because you know better then the doctor? And the house will be a target for break ins? Over a single prescription of pain meds? Not like they are being stock piled.

Must be nice to sit at a cushy job counting pills and making judgement calls on people. Having served in the Army for the past six years I know people who are on pain meds, not for a sore throat but because they lost their leg and have had their hand partially reattached. To say there is no need for this? The people I know on pain medications have gotten their lives back. Its hard enough coming home, but coming home injured makes it harder to readjust. Being able to have the option of these medications have given people the opportunity to play with their children and loved ones again. It’s very rare that the person is a junkie looking for a fix. It’s the opposite, it doesn’t take over their lives but gives it back to them.

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September 26, 2012 @ 11:27 am

[...] who have grown attached to the wit and profanity of some of the earlier blogs).A recent post is "Prudent prescribing or overdone? Should ALL discomfort be treated like this?," which asks the highly relevant question about whether we as a culture overprescribe heavy-duty [...]

Comment by MV

October 6, 2012 @ 1:36 pm

So, as a pharmacist, do you actually do anything about it? Or is it not a professional responsibility? If all you do is fill the prescriptions while noting how common they are and likely inappropriate, then exactly why should anyone see a pharmacist as anything but someone who fills bottles with pills?

While I don’t have much need from pharmacists beyond filling bottles, others may. Unfortunately, pharmacists seem to be doing a great job of minimizing their reputations all by themselves. Ultimately, that’s not good for me either.

Comment by milerapa

November 25, 2012 @ 12:14 am

To the above poster who decided that chronic pain is such a far out condition that it requires quotation marks: I am a 24 year old male. Last year I woke up with sciatic pain down my right leg so bad that all I could do was lie in bed all day writhing in pain. I had an MRI that showed multiple herniated discs, one torn disc, stenosis throughout my ENTIRE lumbar spine and pinched nerves in 4 places. I have tried EVERYTHING to get me back to a somewhat bearable life (one where I can do more than go to work and cry in the bathroom because I hurt so bad and I just want the pain to stop). This includes 6 months of triweekly PT, 3 steroid injections, MASSIVE amounts of NSAIDS (including Celebrex and Meloxicam) Lyrica, Gabapentin, Topomax, Lidocaine patches, a traction device, a TENS unit, a spinal cord stimulator, daily meditation, tai qi, qi gong, yoga, acupuncture, massage, biofeedback and a failed laminectomy/discectomy. The only thing besides the temporary relief of a traction table (which only helps while I am strapped in) that has afforded me ANY quality of life are opiods. Yes, they do give a pleasant buzz the first month or so that you take them but eventually the only benefit gained from being prescribed pain meds is that they provide analgesia. You must have absolutely no idea what it is like to wake up everyday praying that today you’ll feel better and won’t need to take any medication. Unfortunately for people like myself that is never going to happen. I will be in severe pain for the rest of my life. My surgeon told me that there is too many problems for him to fix. My pain management doctor told me that my pain is only going to get worse.. That my back is only going to get worse. So before denouncing something you have no personal experience with think about me. Think about the fact that I have a whole life of pain ahead of me and it’s only going to get worse. Think about the others like me who have to battle pain on a minute by minute basis everyday of their life. Pain medication exists for a reason, not to get people high, but to allow people like me to function in this world. And the reason it is so difficult for legitimate patients to get the medication they need so that they can live life outside of a bed is not just because people abuse these medications, it is also because of narrow minded people claiming that these medications don’t need to exist, that Tylenol or Advil or mind over matter should suffice. I would trade lives with you in a second so that I don’t have to deal with pain like this anymore, actually I wouldn’t. I wouldn’t wish it on anyone else.

Happy Holidays to you all. And I am so sorry that my being able to get out of bed and go to work and school everyday requires you to fill out a few pieces of paper every week on top of counting pills and thinking less of people all day. All while you make $50+ an hour. I am sooo sorry that you chose such an awful profession.

And I apologize for the rant. It has been an especially rough week.
May you all be healthy and happy.

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